Chuck. If the design of the approach makes a false perception inevitable, why is it that only one aircraft, over a long period of time, ended up with CFIT?
No doubt that approach has been flown hundreds of times by many aircraft and pilots; only one accident?
I don’t think there is any dispute the design of the approach could be significantly improved, however it was not fundamentally flawed and if the Transair Metro pilot had flown the approach in accordance with the existing approach parameters, the outcome would have been very different.
The primary question must remain in the operator’s culture which permitted the event to occur and why that culture was not detected by CASA over a prolonged series of rigorous audits?